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Abstract
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In this report, we describe an unusual case of acute poisoning caused by dexmedetomidine-adulterated chewing gum.
A 7-year-old boy was admitted to the Department of Pediatrics and Adolescent Medicine with loss of consciousness. The patient became unarousable shortly after consuming a piece of chewing gum in ordinary packaging. The chewing gum was retrieved from the patient's mouth and he was immediately sent to the hospital. On arrival to the Accident and Emergency department, his blood pressure was 119/76 mmHg, with pulse rate of 76 beats per minute and respiratory rate of 22 breaths per minute. He was unresponsive with a Glasgow Coma Score of 4/15 (E1V2M1). Pinpoint pupils were observed, so opioid overdose was initially suspected and naloxone was given. Initial laboratory investigations, including arterial blood gas, complete blood count, clotting profile, liver and renal functions, electrolytes, blood glucose and ammonia were all unremarkable. Ethanol level in the blood was undetectable. Computed tomography of the brain did not reveal any focal lesion or abnormality. The patient was admitted to the paediatrics intensive care unit (PICU) for close monitoring and endotracheal intubation was performed for airway protection. He gradually regained consciousness and was extubated on the following day. He recovered uneventfully and was discharged a week after admission. Further follow-up physical examination and brain imaging at 2 months after discharge showed absence of long-term sequelae.
Toxicology investigation was performed on the chewing gum remains and patient's urine specimen. ... Dexmedetomidine was detected in both the chewing gum remains and the patient's urine specimen. Other drugs detected in the urine, including midazolam, naloxone and rocuronium, were all given after hospitalisation.
Dexmedetomidine is an alpha-2 adrenergic receptor agonist with sedative, anxiolytic, analgesic and cardiovascular stabilising effects. It is notable for its ability to achieve sedation without significant respiratory depression. Dexmedetomidine was developed in the 1980s and approved by the Food and Drug Administration for human use in 1999. It has a distribution half-life of 6 minutes and plasma half-life of 2 hours. Common uses include sedation in intensive care and for paediatric procedures, controlled hypotension, locoregional analgesia, and as adjunct analgesia in surgeries to reduce morphine requirement. The recommended route of administration is intravenous and the usual dosage is 0.2-0.7 μg/kg/hr. Oral bioavailability is poor due to first-pass metabolism but sublingual bioavailability is high. In Hong Kong, dexmedetomidine is a prescription-only medication and only available as injection or infusion solution. Recent studies show that intranasal administration of dexmedetomidine is effective and safe for sedation in paediatric patients. Dexmedetomidine is metabolised through N-glucuronidation and hydroxylation. Most inactive metabolites are excreted renally. Common side effects include coma, dry mouth, hypotension, and bradycardia. Less common adverse effects include hypothermia, cardiac arrhythmias including AV block, pulmonary oedema and convulsions. The pupils may be constricted or dilated. In case of overdose, the management is supportive treatment for hypotension, bradycardia and other adverse effects. Maintaining a clear airway and ensuring adequate ventilation is important. The benefit of gastric decontamination is uncertain and no antidote is available.
Dexmedetomidine identified in the patient's urine and the chewing gum was the sole agent that could explain the patient's clinical presentation. The presence of dexmedetomidine in chewing gum is highly unusual. The source of the chewing gum was a mystery. The patient lived and studied in Hong Kong but he travelled to mainland China a few times every year to visit his relatives. According to the patient, the chewing gum just 'appeared' in his bag during his last visit to mainland China (August 2019); presumably it was placed there by an unknown person. Although drug-facilitated crime was suspected, the actual intention remained undetermined.
Recently, dexmedetomidine-adulterated chewing gum has been reported as used in drug-facilitated sexual assault (DFSA) in Taiwan and China. This type of sedative chewing gum, packaged as ordinary Wrigley's Doublemint or Juicy Fruit chewing gum, can be purchased through the internet. According to the product description, the chewing gum can cause immediate decrease in consciouness upon consumption with effects lasting for 3-5 hours. Since this type of chewing gum is easily obtainable, it can be a potential threat to the general public.
Language: en |